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TIP 35Enhancing Motivation for Change in Substance Use Disorder TreatmentIntended AudienceThe primary audiences for this TIP are: Drug and alcohol treatment service providers.Mental health service providers, such aspsychologists, licensed clinical social workers,and psychiatric/mental health nurses.Peer recovery support specialists.Behavioral health program managers, directors,and administrators.Clinical supervisors.Healthcare providers, such as primary carephysicians, nurse practitioners, general/familymedicine practitioners, registered nurses,internal medicine specialists, and others whomay need to enhance motivation to addresssubstance misuse in their patients.Secondary audiences include preventionspecialists, educators, and policymakers for SUDtreatment and related services.Overall Key MessagesMotivation is key to substance use behaviorchange. Counselors can support clients’ movementtoward positive changes in their substance useby identifying and enhancing motivation thatalready exists.Motivational approaches are based on theprinciples of person-centered counseling.Counselors’ use of empathy, not authority andpower, is key to enhancing clients’ motivation tochange. Clients are experts in their own recoveryfrom SUDs. Counselors should engage them incollaborative partnerships.Ambivalence about change is normal.Resistance to change is an expression ofambivalence about change, not a client traitor characteristic. Confrontational approachesincrease client resistance and discord in thecounseling relationship. Motivational approachesexplore ambivalence in a nonjudgmental andcompassionate way.The Transtheoretical Model (TTM) of the SOCapproach is an overarching framework that helpsxcounselors tailor specifc counseling strategiesto different stages. Motivational counselingstrategies should be tailored to clients’ level ofmotivation to change their substance use behaviorsat each of the fve stages of the SOC: tenanceEffective motivational counseling approachescan be brief. A growing body of evidenceindicates that early and brief interventionsdemonstrate positive treatment outcomes in awide variety of settings including specialty SUDtreatment programs, primary care offces, andemergency departments. Brief interventionsemphasize reducing the health-related riskof a person’s substance use and decreasingconsumption as an important treatment outcome.Motivational interviewing (MI) and othermotivational counseling approaches likemotivational enhancement therapy are effectiveways to enhance motivation throughout theSOC. Motivational counseling approaches arebased on person-centered counseling principlesthat focus on helping clients resolve ambivalenceabout changing their substance use and otherhealth-risk behaviors.MI is the most widely researched anddisseminated motivational counselingapproach in SUD treatment. The spirit of MI(i.e., partnership, acceptance, compassion,and evocation) is the foundation of the corecounseling skills required for enhancing clients’motivation to change. The core counseling skillsof MI are described in the acronym OARS (Openquestions, Affrmations, Refective listening,and Summarization).Counselor empathy, as expressed throughrefective listening, is fundamental to MI. Useof empathy, rather than power and authoritativeapproaches, is critical for helping clients achieveand maintain lasting behavior change.

TIP 35Adaptations of MI enhance the implementationand integration of motivational interventionsinto standard treatment methods. Training,ongoing supervision, and coaching of counselorsare essential for workforce development andintegration of motivational counseling approachesinto SUD treatment. Content OverviewChapter 1—A New Look at MotivationThis chapter lays the groundwork forunderstanding treatment concepts discussedlater in the TIP. It is an overview of the nature ofmotivation and its link to changing substanceuse behaviors. The chapter describes changingperspectives on addiction and addiction treatmentin the United States and uses the TTM of theSOC approach as an overarching framework tounderstand how people change their substanceuse behaviors.In Chapter 1, readers will learn that: Motivation is essential to substance usebehavior change. It is multidimensional,dynamic, and fuctuating; can be enhanced; andis infuenced by the counselor’s style.Benefts of using motivational counselingapproaches include clients’ enhancingmotivation to change, preparing them to entertreatment, engaging and retaining clients intreatment, increasing their participation andinvolvement in treatment, improving theirtreatment outcomes, and encouraging a rapidreturn to treatment if they start misusingsubstances again.New perspectives on addiction treatmentinclude focusing on clients’ strengthsinstead of defcits, offering person-centeredtreatment, shifting away from labeling clients,using empathy, focusing on early and briefinterventions, recognizing that there is a rangeof severity of substance misuse, accepting riskreduction as a legitimate treatment goal, andproviding access to integrated care.People go through stages in the SOC approach;this concept is known as the TTM of change.The stages in the SOC model are:- Precontemplation, in which people are notconsidering change.- Contemplation, in which people areconsidering change but are unsure howto change.- Preparation, in which people have identifeda change goal and are forming a planto change.- Action, in which people are taking stepsto change.- Maintenance, in which people have mettheir change goal and the behavior changeis stable.Chapter 2—Motivational Counseling andBrief InterventionThis chapter is an overview of motivationalcounseling approaches, including screening, briefintervention, and referral to treatment (SBIRT).It describes elements of effective motivationalcounseling approaches, including FRAMES(Feedback, Responsibility, Advice, Menu ofoptions, Empathy, and Self-effcacy), decisionalbalancing, discrepancy development, fexiblepacing, and maintenance of contact with clients.The chapter describes counselors’ focus in eachstage of the SOC model. It addresses specialapplications of motivational counseling withclients from diverse cultures and with clients whohave co-occurring substance use and mentaldisorders (CODs).In Chapter 2, readers will learn that: Each stage in the SOC approach haspredominant experiential and behavioralcatalysts for client change on which counselorsshould focus.Counselors should adopt the principles ofcultural responsiveness and adapt motivationalinterventions to those principles when treatingclients from diverse backgrounds.Even mild substance misuse can impedefunctioning in people with CODs, includingco-occurring severe mental illness. Counselorscan adapt motivational interventions forthese clients.xi

TIP 35 Enhancing Motivation for Change in Substance Use Disorder TreatmentBrief motivational interventions, including SBIRT,are effective in specialty SUD treatment facilitiesand opportunistic settings (e.g., primary careoffces, emergency departments).Brief interventions emphasize risk reductionand referral to specialty addiction treatmentif needed.Chapter 3—Motivational Interviewing asa Counseling StyleThis chapter provides an overview of the spirit ofMI, the principles of person-centered counseling,the core counseling skills of MI (i.e. asking openquestions, affrming, refective listening, andsummarizing), and the four processes of MI (i.e.,engaging, focusing, evoking, and planning). Itdescribes what’s new in MI and dispels manymisconceptions about MI. The chapter discussesthe components that counselors use to help clientsresolve ambivalence and move toward positivesubstance use behavior change.In Chapter 3, readers will learn that: Ambivalence about substance use and change isnormal and a motivational barrier to substanceuse behavior change, if not explored.The spirit of MI embodies the principles ofperson-centered counseling and is the basis ofan empathetic, supportive counseling style.Sustain talk is essentially statements the clientmakes for not changing (i.e., maintaining thestatus quo), and change talk is statementsthe client makes in favor of change. The keyto helping the client move in the directiontoward changing substance use behaviorsis to evoke change talk and soften or lessenthe impact of sustain talk on the client’sdecision-making process.The acronym OARS describes the core skillsof MI:- Asking Open questions- Affrming the client’s strengths- Using Refective listening- Summarizing client statementsRefective listening is fundamental to personcentered counseling in general and MI inparticular and is essential for expressingempathy.xii The four processes in MI (i.e., engaging,focusing, evoking, and planning) provide anoverarching framework for employing the coreskills in conversations with a client.The benefts of MI include its broad applicabilityto diverse medical and behavioral healthproblems and its capacity to complementother counseling approaches and to mobilizeclient resources.Chapter 4—From Precontemplation toContemplation: Building ReadinessThis chapter discusses strategies counselorscan use to help clients raise doubt and concernabout their substance use and move towardcontemplating the possibility of change. Itemphasizes the importance of assessing clients’readiness to change, providing personalizedfeedback to them about the effects and risksof substance misuse, involving their signifcantothers in counseling to raise concern aboutclients’ substance use behaviors, and addressingspecial considerations for treating clients who aremandated to treatment.In Chapter 4, readers will learn that: A client in the Precontemplation stage isunconcerned about substance use or is notconsidering change.The counselor’s focus in Precontemplation isto establish a strong counseling alliance andraise the client’s doubts and concerns aboutsubstance use.Key strategies in this stage include eliciting theclient’s perception of the problem, exploringthe events that led to entering treatment, andidentifying the client’s style of Precontemplation.Providing personalized feedback on assessmentresults and involving signifcant others incounseling sessions are key strategies forraising concern and moving the client towardcontemplating change.Special considerations in motivationalcounseling approaches for clients mandatedto treatment include acknowledging clientambivalence and emphasizing personal choiceand responsibility.

TIP 35Chapter 5—From Contemplation toPreparation: Increasing CommitmentThis chapter describes strategies to increaseclients’ commitment to change by normalizingand resolving ambivalence and enhancing theirdecision-making capabilities. It emphasizesdecisional balancing and exploring clients’ selfeffcacy as important to moving clients towardpreparing to change substance use behaviors.Summarizing change talk and exploring theclient’s understanding of change prepare clients totake action. In Chapter 5, readers will learn that: In the Contemplation stage, the clientacknowledges concerns about substance useand is considering the possibility of change.The counselor’s focus in Contemplation is tonormalize and resolve client ambivalence andhelp the client tip the decisional balance towardchanging substance use behaviors.Key motivational counseling strategies forresolving ambivalence include reassuring theclient that ambivalence about change is normal;evoking DARN (Desire, Ability, Reasons, andNeed) change talk; and summarizing theclient’s concerns.To reinforce movement toward change, thecounselor reinforces the client’s understandingof the change process, reintroducespersonalized feedback, explores client selfeffcacy, and summarizes client change talk.The counselor encourages the client tostrengthen his or her commitment to change bytaking small steps, going public, and envisioninglife after changing substance use behaviors.Chapter 6—From Preparation to Action:Initiating ChangeThis chapter describes the process of helpingclients identify and clarify change goals. It alsofocuses on how and when to develop changeplans with clients and suggests ways to ensure thatplans are accessible, acceptable, and appropriatefor clients.In Chapter 6, readers will learn that: In the Preparation stage, the client is committedand planning to make a change but is unsure ofwhat to do next. In the Action stage, the clientis actively taking steps to change but has notreached stable recovery.In Preparation, the counselor focuses on helpingthe client explore change goals and develop achange plan. In Action, the counselor focuses onsupporting client action steps and helping theclient evaluate what is working and not workingin the change plan.The client who is committed to change and whobelieves change is possible is prepared for theAction stage.Sobriety sampling, tapering down, and trialmoderation are goal-sampling strategiesthat may be helpful to the client who is notcommitted to abstinence as a change goal.Creating a change plan is an interactive processbetween the counselor and client. The clientshould determine and drive change goals.Identifying and helping the client reducebarriers to the Action stage are important to thechange-planning process.Counselors can support client action byreinforcing client commitment and continuingto evoke and refect CAT (i.e., Commitment,Activation, and Taking steps) change talk inongoing conversations.Chapter 7—From Action to Maintenance:Stabilizing ChangeThis chapter addresses ways in which motivationalstrategies can be used effectively to help clientsmaintain the gains they have made by stabilizingchange, supporting lifestyle changes, managingsetbacks during the Maintenance stage, andhelping them reenter the cycle of change ifthey relapse or return to substance misuse. Itemphasizes creating a coping plan to reduce therisk of recurrence in high-risk situations, identifyingnew behaviors that reinforce change, andestablishing relapse prevention strategies.In Chapter 7, readers will learn that: During the Maintenance stage, the client hasachieved the initial change goals and is workingtoward maintaining those changes.xiii

TIP 35 Enhancing Motivation for Change in Substance Use Disorder TreatmentIn Maintenance, the counselor focuses onhelping the client stabilize change and supportsthe client’s lifestyle changes.During a relapse, the client returns tosubstance misuse and temporarily exitsthe change cycle. The counselor focuseson helping the client reenter the cycle ofchange and providing relapse preventioncounseling in accordance with the principles ofperson-centered counseling.Maintenance of substance use behavior changein the SOC model must address the issue ofrelapse. Relapse should be reconceptualizedas a return to or recurrence of substance usebehaviors and viewed as a common occurrence.Relapse prevention counseling is a cognitive–behavioral therapy (CBT) method, but thecounselor can use motivational counselingstrategies to engage the client in the processand help the client resolve ambivalence aboutlearning and practicing new coping skills.Strategies to help a client reenter the changecycle after a recurrence include affrmingthe client’s willingness to reconsider positivechange, exploring reoccurrence as a learningopportunity, helping the client fnd alternativecoping strategies, and maintaining supportivecontact with the client.Chapter 8—Integrating MotivationalApproaches in SUD Treatment SettingsThis chapter discusses some of the adaptationsof motivational counseling approaches applicableto SUD treatment programs and workforcedevelopment issues that treatment programsshould address to fully integrate and sustainmotivational counseling approaches. It emphasizesblending MI with other counseling approaches.It also explores ways in which ongoing training,supervision, and coaching are essential tosuccessful workforce development and integration.In Chapter 8, readers will learn that: Integrating motivational counseling approachesinto a treatment program requires a broadintegration of the philosophy and underlyingspirit of MI throughout the organization.xiv Adapted motivational interventions may bemore cost effective, accessible to clients,and easily integrated into existing treatmentapproaches than expected and may ease someworkload demands on counselors.Technology adaptations, including motivationalcounseling and brief interventions over thephone or via text messaging, are effective,cost effective, and adaptable to differentclient populations.MI is effective when blended withother counseling approaches includinggroup counseling, the motivationalinterviewing assessment, CBT, and recoverymanagement checkups.The key to workforce development is to trainall clinical and support staffs in the spirit ofMI so that the entire program’s philosophy isaligned with person-centered principles, likeemphasizing client autonomy and choice.Program administrators should assess theorganization’s philosophy and where it isin the SOC model before implementing atraining program.Training counseling staff in MI takes more thana 1- or 2-day workshop. Maintenance of skillsrequires ongoing training and supervision.Supervision and coaching in MI should becompetency based. These activities requiredirectly observing the counselor’s skill level andusing coding instruments to assess counselorfdelity. Supervision should be performed in thespirit of MI.Administrators need to balance training,supervision, and strategies to enhancecounselor fdelity to MI with costs, whilepartnering with counseling staff to integrate amotivational counseling approach throughoutthe organization.

TIP 35TIP Development ParticipantsConsensus PanelEach Treatment Improvement Protocol’s (TIP)consensus panel is a group of primarily nonfederaladdiction-focused clinical, research, administrative,and recovery support experts with deepknowledge of the TIP’s topic. With the SubstanceAbuse and Mental Health Services Administration’sKnowledge Application Program team, membersof the consensus panel develop each TIP via aconsensus-driven, collaborative process that blendsevidence-based, best, and promising practiceswith the panel members’ expertise and combinedwealth of experience.ChairWilliam R. Miller, Ph.D.Regents Professor of Psychology and PsychiatryDirector of ResearchCenter on Alcoholism, Substance Abuse, andAddictionsDepartment of PsychologyUniversity of New MexicoAlbuquerque, New MexicoWorkgroup LeadersEdward Bernstein, M.D., F.A.C.E.P.Associate Professor and Academic AffairsVice ChairmanBoston University School of MedicineBoston, MassachusettsSuzanne M. Colby, Ph.D.Assistant Professor of Psychiatry and HumanBehaviorCenter for Alcohol and Addiction StudiesBrown UniversityProvidence, Rhode IslandCarlo C. DiClemente, Ph.D.Department of PsychologyUniversity of Maryland, Baltimore CountyBaltimore, MarylandRobert J. Meyers, M.A.Center on Alcoholism, Substance Abuse, andAddictionsUniversity of New MexicoAlbuquerque, New MexicoMaxine L. Stitzer, Ph.D.Professor of Psychiatry and Behavioral BiologyJohns Hopkins University School of MedicineBaltimore, MarylandAllen Zweben, D.S.W.Director and Associate Professor of Social WorkCenter for Addiction and Behavioral HealthResearchUniversity of Wisconsin at MilwaukeeMilwaukee, WisconsinPanelistsRay DawExecutive DirectorNorthwest New Mexico Fighting Back, Inc.Gallup, New MexicoJeffrey M. Georgi, M.Div., C.S.A.C., C.G.P.Program CoordinatorDuke Alcoholism and Addictions ProgramClinical AssociateDepartment of Psychiatry and Behavioral ScienceDuke University Medical CenterDurham, North CarolinaCheryl Grills, Ph.D.Department of PsychologyLoyola Marymou

TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment Chapter 6—From Preparation to Action: Initiating Change 95 Explore Client Change Goals 96 Develop a Change Plan 99 Support t